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Briefings on Coding Compliance Strategies (Single Article)
It’s official: Coders can code from nonphysician documentation
November 2005
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Product Description:
Physician assistant, nurse practitioner notes permitted
Official coding guidelines released in the fourth quarter of 2004 state that coding/HIM professionals can code inpatient claims--including diagnoses and procedures--from nurse practitioner and physician assistant notes in the chart. But many hospital coders aren’t aware of this information, says Darlene Fawaz, RHIT, compliance audit specialist in corporate compliance for a large acute-care health system in Michigan.
Fawaz says coding/HIM professionals were formerly only allowed to report diagnoses and procedures documented by the attending physician or physicians caring for the patient during the admission. Most of the advice written for inpatient coding refers to physician documentation and querying the physician for clarification.
